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Further Studies Concerning Homatropine Cycloplegia and Paredrine, by Special Reference to the Rate of Accommodative Recovery*
F U R T H E R STUDIES CONCERNING H O M A T R O P I N E CYCLOPLEGIA AND PAREDRINE, W I T H SPECIAL R E F E R E N C E TO T H E RATE O F ACCOMMODATIVE RECOVERY* WILLIAM F. MONCREIFF, M.D.,
AND KARL J. SCHERIBEL,
M.D.
Chicago, Illinois
On May 13, 1940, we reported 1 before this Society the results of our work on a series of 83 patients, showing by strictly comparative tests that the cycloplegic effi ciency of homatropine is not enhanced by the use of either Benzedrine sulfate or paredrine. In that study we did not fully investigate the possibility that these drugs may act to hasten the recovery from homatropine cycloplegia. Since then we have studied this question in greater de tail in 36 patients, the data obtained com prising the substance of this report. The selection of patients, the plan of proce dure, and the techniques of examination and of instillation of solutions have been similar in this work to that previously re ported. The following abbreviations are used, as in the first paper : HA = S-percent homatropine alone, 2 drops HP = S-percent homatropine, 2 drops; 1-per cent paredrine, 1 drop H2% = 2-percent homatropine alone, 6 drops In addition to the literature reviewed in our previous report, there is a paper en titled "A study of practical cycloplegia," by Wenaas, Evans, and Odom,2 which appeared in October, 1940, after our pres ent work was well under way. These authors, using the same method of testing residual accommodation, have confirmed our findings (which were not published until March, 1941) of the lack of a synergistic action by paredrine in homat ropine cycloplegia. They also state, with out presenting much supporting data, that the addition of paredrine does not hasten * From the Department of Ophthalmology, Rush Medical College. Read before the Chicago Ophthalmological Society, November 17, 1941. 839
the accommodative recovery from homat ropine. They, as well as other' authors whom they cite, consider that cycloplegia is adequate even with 2 D. of residual ac commodation, whereas we believe, with Duane, that more than 1 D. of residual accommodation means the probability of insufficient cycloplegia. We agree, how ever, with their principal conclusion, to the effect that the dosage of cycloplegics could be more accurately adapted to the differing requirements of individual pa tients than is usually effected, also with their statement that accommodative re covery from homatropine cycloplegia is not hastened by the addition of paredrine. As in the first paper, we show in table 1 the characteristics of our clinical ma terial, and in table 2 that in this series, also, evidence is lacking that paredrine actually enhances the cycloplegic effect of homatropine. The results of our studies of accommodative recovery are presented graphically in figures 1 to 10, and by the percentage method in table 3. Tests were made at 2-hour intervals for the first 8 hours, and also at the end of 24 hours. f The artificial-myopia test was employed until the near point for small test type (Jaeger 1 or 4 point) had recovered to 33 cm. or less, after which near-point tests with only the full refractive correction were also made. Careful study of these charts discloses that the addition of paredrine does not appreciably shorten the duration of hot T h e authors wish to express their thanks to Drs. G. Phelps, M. M. Schemer, M. D. Hursh, and Y. A. Staton, former residents at Presbyterian Hospital, for technical assistance rendered in making these tests.
840
WILLIAM F. MONCREIFF AND KARL J. SCHERIBEL TABLE 1 RÉSUMÉ OF FACTORS CONCERNING PATIENTS, EYES, VISION, AND REFRACTION Series 1
Series 2
16 to 35 20 to 35 under 16 over 35
26 52 12 to 38 No. 17 or 6 5 % 10 or 3 8 % 8 or 3 1 % 1 or 4 %
10 20 15 to 29 No. 8 or 8 0 % 2 or 2 0 % 2 or 2 0 % 0
36 72 12 to 38 No. 25 or 7 0 % 12 or 3 3 % 10 or 2 7 % 1 or 3 %
Color of iris (patients) Brown Blue
11 or 4 2 % 15 or 5 8 %
2 or 2 0 % 8 or 8 0 %
13 or 3 6 % 23 or 6 4 %
Corrected vision (eyes) 1.2-2 1.2-1 to 1.5
1 or 2 % 51 or 9 8 %
1 or 5 % 19 or 9 5 %
. 2 or 2 . 5 % 70 or 9 7 . 5 %
Refraction factors (eyes) Highest meridian over 3.00D. Highest meridian 1.25D..to 3.00D. Highest meridian 1.00D. or less Over 1.00D. cylinder
2 9 41 2
1 or 5 % 8 or 4 0 % 11 or 5 5 % 0
3 17 52 2
Number of patients Number of eyes Range of ages Age Age Age Age
Variations in refraction findings (eyes) Differences of over 0.25D. Differences of over 0 . 5 0 D .
or 4 % or 17% or 7 9 % or 4 %
4 or 8% 0
Totals
1 or 5 % 0
or 4 % or 24% or 72% or 2 . 5 %
5 or 7 % 0
TABLE 2 RESIDUAL ACCOMMODATION AT TIME OF REFRACTION TEST (72 EYES) Series 1 (52 eyes)
1.50D.
1.25D.
1.00D.
0.75D.
0.50D.
0.25D.
Totals
0 0 0
0 3 3
6 6 12
13 9 22
10 4 14
1 0 1
30 eyes 22 eyes 52 eyes
5 % Homatropine alone (HA) Blue iris Brown iris Totals
0 1 1
1 2 3
9 8 17
12 6 18
8 5 13
0 0 0
30 eyes 22 eyes 52 eyes
Series (20 eyes) 5 % Homatropine alone (HA) 2 % Homatropine alone (H2%)
0 1
0 2
11 12
7 3
2 2
0 0
20 eyes 20 eyes
Paredrine Homatropine Blue iris Brown iris Totals
(HP)
matropine cycloplegia. This was found even in a few cases in which 3 or more drops of paredrine were used instead of one. It is further demonstrated by the percentage figures in table 3, where the differences are too slight to be significant ly in favor of paredrine as a factor has tening recovery.
Since practically all of these patients were young, and the majority had low hyperopia, analysis of these factors yields nothing worthy of comment. In fact, pa tients of these types were selected so as to avoid the introduction of such extraneous factors, and to prevent the inclusion of patients with low accommodative power.
Figs. 1 to 6 (Moncreiff and Scheribel). Graphic presentation of results of accommodative-recovery studies. Fig. 1. Series 1. Accommodative recovery (average). Fig. 2. Series 2. Accommodative recovery (average). Fig. 3. Series 1. Accommodative recovery (average). HP. Fig. 4. Series 1. Accommo dative recovery (average). HA. Fig. 5. Series 1. Accommodative recovery (average). Blue iris. Fig. 6. Series 1. Accommodative recovery (average). Brown iris.
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WTLLIAM F. M O N C R E I F F A N D K A R L J. S C H E R I B E L
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Figs. 7 to 10 (Moncreiff and Scheribel). Graphic presentation of results of accommodativerecovery studies. Fig. 7. Series 2. Accommodative recovery (average). HA. Fig. 8. Series 2. Accommodative recovery (average). H 2 percent. Fig. 9. Series 2. Accommodative recovery (average). Blue iris. Fig. 10. Series 2. Accommodative recovery (average). Brown iris.
The factor of iris color, which in about two thirds of the cases was blue, has not proved to be especially significant in regard to accommodative recovery at the end of 24 hours.
In 10 patients, an additional study was made of the comparative efficiency and of the rate of recovery between 2 drops of 5-percent homatropine and 6 drops of 2percent homatropine. While the number
HOMATROPINE CYCLOPLEGIA AND PAREDRINE of patients is small, the comparison did not show the 2-percent homatropine dos age to be the more efficient ( r a t h e r the c o n t r a r y ) , nor was there a more rapid recovery from the 5-percent homatropine (as one might anticipate), but rather the reverse.
TABLE 3 ACCOMMODATIVE RECOVERY IN PERCENTAGES OF TOTAL ACCOMMODATION (AVERAGE)
Time
8 hours 24 hours
S U M M A R Y AND CONCLUSIONS
F u r t h e r studies on carefully selected patients show good clinical evidence that the rate of recovery from homatropine cycloplegia is not hastened by the action of paredrine. Additional evidence is also presented that the efficiency of homat ropine cycloplegia is not enhanced by paredrine.
843
Series 1 (52 eyes) 10.35D. Average Accommodation
Series 2 (20 eyes) 9.90D. Average Accommodation
HP
HA
HA
H2%
32.6% 61.5%
34.2% 60.4%
19.8% 61.6%
32.7% 78.2%
In a series of 10 patients, the action of 2 drops of 5-percent homatropine was found not to be superior to that of 6 drops of 2-percent homatropine with regard to either the efficiency of the cycloplegia or the rapidity of recovery. 58 East Washington Street. 55 East Washington Street.
REFERENCES 1 J
Moncreiff, W. F., and Scheribel, K. J. Amer. Jour. Ophth., 1941, v. 24, Mar., p. 282. Wenaas, E. J., Evans, W. H., and Odom, R. E. Amer. Jour. Ophth., 1940, v. 23, Oct., p. 1123.
AND KARL J. SCHERIBEL,
M.D.
Chicago, Illinois
On May 13, 1940, we reported 1 before this Society the results of our work on a series of 83 patients, showing by strictly comparative tests that the cycloplegic effi ciency of homatropine is not enhanced by the use of either Benzedrine sulfate or paredrine. In that study we did not fully investigate the possibility that these drugs may act to hasten the recovery from homatropine cycloplegia. Since then we have studied this question in greater de tail in 36 patients, the data obtained com prising the substance of this report. The selection of patients, the plan of proce dure, and the techniques of examination and of instillation of solutions have been similar in this work to that previously re ported. The following abbreviations are used, as in the first paper : HA = S-percent homatropine alone, 2 drops HP = S-percent homatropine, 2 drops; 1-per cent paredrine, 1 drop H2% = 2-percent homatropine alone, 6 drops In addition to the literature reviewed in our previous report, there is a paper en titled "A study of practical cycloplegia," by Wenaas, Evans, and Odom,2 which appeared in October, 1940, after our pres ent work was well under way. These authors, using the same method of testing residual accommodation, have confirmed our findings (which were not published until March, 1941) of the lack of a synergistic action by paredrine in homat ropine cycloplegia. They also state, with out presenting much supporting data, that the addition of paredrine does not hasten * From the Department of Ophthalmology, Rush Medical College. Read before the Chicago Ophthalmological Society, November 17, 1941. 839
the accommodative recovery from homat ropine. They, as well as other' authors whom they cite, consider that cycloplegia is adequate even with 2 D. of residual ac commodation, whereas we believe, with Duane, that more than 1 D. of residual accommodation means the probability of insufficient cycloplegia. We agree, how ever, with their principal conclusion, to the effect that the dosage of cycloplegics could be more accurately adapted to the differing requirements of individual pa tients than is usually effected, also with their statement that accommodative re covery from homatropine cycloplegia is not hastened by the addition of paredrine. As in the first paper, we show in table 1 the characteristics of our clinical ma terial, and in table 2 that in this series, also, evidence is lacking that paredrine actually enhances the cycloplegic effect of homatropine. The results of our studies of accommodative recovery are presented graphically in figures 1 to 10, and by the percentage method in table 3. Tests were made at 2-hour intervals for the first 8 hours, and also at the end of 24 hours. f The artificial-myopia test was employed until the near point for small test type (Jaeger 1 or 4 point) had recovered to 33 cm. or less, after which near-point tests with only the full refractive correction were also made. Careful study of these charts discloses that the addition of paredrine does not appreciably shorten the duration of hot T h e authors wish to express their thanks to Drs. G. Phelps, M. M. Schemer, M. D. Hursh, and Y. A. Staton, former residents at Presbyterian Hospital, for technical assistance rendered in making these tests.
840
WILLIAM F. MONCREIFF AND KARL J. SCHERIBEL TABLE 1 RÉSUMÉ OF FACTORS CONCERNING PATIENTS, EYES, VISION, AND REFRACTION Series 1
Series 2
16 to 35 20 to 35 under 16 over 35
26 52 12 to 38 No. 17 or 6 5 % 10 or 3 8 % 8 or 3 1 % 1 or 4 %
10 20 15 to 29 No. 8 or 8 0 % 2 or 2 0 % 2 or 2 0 % 0
36 72 12 to 38 No. 25 or 7 0 % 12 or 3 3 % 10 or 2 7 % 1 or 3 %
Color of iris (patients) Brown Blue
11 or 4 2 % 15 or 5 8 %
2 or 2 0 % 8 or 8 0 %
13 or 3 6 % 23 or 6 4 %
Corrected vision (eyes) 1.2-2 1.2-1 to 1.5
1 or 2 % 51 or 9 8 %
1 or 5 % 19 or 9 5 %
. 2 or 2 . 5 % 70 or 9 7 . 5 %
Refraction factors (eyes) Highest meridian over 3.00D. Highest meridian 1.25D..to 3.00D. Highest meridian 1.00D. or less Over 1.00D. cylinder
2 9 41 2
1 or 5 % 8 or 4 0 % 11 or 5 5 % 0
3 17 52 2
Number of patients Number of eyes Range of ages Age Age Age Age
Variations in refraction findings (eyes) Differences of over 0.25D. Differences of over 0 . 5 0 D .
or 4 % or 17% or 7 9 % or 4 %
4 or 8% 0
Totals
1 or 5 % 0
or 4 % or 24% or 72% or 2 . 5 %
5 or 7 % 0
TABLE 2 RESIDUAL ACCOMMODATION AT TIME OF REFRACTION TEST (72 EYES) Series 1 (52 eyes)
1.50D.
1.25D.
1.00D.
0.75D.
0.50D.
0.25D.
Totals
0 0 0
0 3 3
6 6 12
13 9 22
10 4 14
1 0 1
30 eyes 22 eyes 52 eyes
5 % Homatropine alone (HA) Blue iris Brown iris Totals
0 1 1
1 2 3
9 8 17
12 6 18
8 5 13
0 0 0
30 eyes 22 eyes 52 eyes
Series (20 eyes) 5 % Homatropine alone (HA) 2 % Homatropine alone (H2%)
0 1
0 2
11 12
7 3
2 2
0 0
20 eyes 20 eyes
Paredrine Homatropine Blue iris Brown iris Totals
(HP)
matropine cycloplegia. This was found even in a few cases in which 3 or more drops of paredrine were used instead of one. It is further demonstrated by the percentage figures in table 3, where the differences are too slight to be significant ly in favor of paredrine as a factor has tening recovery.
Since practically all of these patients were young, and the majority had low hyperopia, analysis of these factors yields nothing worthy of comment. In fact, pa tients of these types were selected so as to avoid the introduction of such extraneous factors, and to prevent the inclusion of patients with low accommodative power.
Figs. 1 to 6 (Moncreiff and Scheribel). Graphic presentation of results of accommodative-recovery studies. Fig. 1. Series 1. Accommodative recovery (average). Fig. 2. Series 2. Accommodative recovery (average). Fig. 3. Series 1. Accommodative recovery (average). HP. Fig. 4. Series 1. Accommo dative recovery (average). HA. Fig. 5. Series 1. Accommodative recovery (average). Blue iris. Fig. 6. Series 1. Accommodative recovery (average). Brown iris.
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WTLLIAM F. M O N C R E I F F A N D K A R L J. S C H E R I B E L
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10
2
4
6
24
3 Time in houre
Figs. 7 to 10 (Moncreiff and Scheribel). Graphic presentation of results of accommodativerecovery studies. Fig. 7. Series 2. Accommodative recovery (average). HA. Fig. 8. Series 2. Accommodative recovery (average). H 2 percent. Fig. 9. Series 2. Accommodative recovery (average). Blue iris. Fig. 10. Series 2. Accommodative recovery (average). Brown iris.
The factor of iris color, which in about two thirds of the cases was blue, has not proved to be especially significant in regard to accommodative recovery at the end of 24 hours.
In 10 patients, an additional study was made of the comparative efficiency and of the rate of recovery between 2 drops of 5-percent homatropine and 6 drops of 2percent homatropine. While the number
HOMATROPINE CYCLOPLEGIA AND PAREDRINE of patients is small, the comparison did not show the 2-percent homatropine dos age to be the more efficient ( r a t h e r the c o n t r a r y ) , nor was there a more rapid recovery from the 5-percent homatropine (as one might anticipate), but rather the reverse.
TABLE 3 ACCOMMODATIVE RECOVERY IN PERCENTAGES OF TOTAL ACCOMMODATION (AVERAGE)
Time
8 hours 24 hours
S U M M A R Y AND CONCLUSIONS
F u r t h e r studies on carefully selected patients show good clinical evidence that the rate of recovery from homatropine cycloplegia is not hastened by the action of paredrine. Additional evidence is also presented that the efficiency of homat ropine cycloplegia is not enhanced by paredrine.
843
Series 1 (52 eyes) 10.35D. Average Accommodation
Series 2 (20 eyes) 9.90D. Average Accommodation
HP
HA
HA
H2%
32.6% 61.5%
34.2% 60.4%
19.8% 61.6%
32.7% 78.2%
In a series of 10 patients, the action of 2 drops of 5-percent homatropine was found not to be superior to that of 6 drops of 2-percent homatropine with regard to either the efficiency of the cycloplegia or the rapidity of recovery. 58 East Washington Street. 55 East Washington Street.
REFERENCES 1 J
Moncreiff, W. F., and Scheribel, K. J. Amer. Jour. Ophth., 1941, v. 24, Mar., p. 282. Wenaas, E. J., Evans, W. H., and Odom, R. E. Amer. Jour. Ophth., 1940, v. 23, Oct., p. 1123.